Sign up to Go on a Mission Trip!

Welcome to the online application for 1st Presbyterian adult mission trips! We are excited you are interested in going on a global trip with us this year. Please fill out all of the information below to help us get you fully registered. Note that you will need a copy of your passport and health insurance information to complete the application, and there is a $300 deposit for every person going on a trip. If you want to learn more about the trips, click here. Please contact Amy Carlan, 336-723-1621 x228 if you have any questions.

Which trip?*

Fall DR Trip Oct 14 -21

Haiti Medical Trip Oct 28- Nov.11

Full Name (as listed on passport)*

Address*

Street AddressCityStateZIP Code

Primary Phone*

Email*

Birthday*

Gender*

Male

Female

Marital Status*

Single

Married

Divorced

Widowed

Spouse's Name

FirstLast

T-shirt size

Small

Medium

Large

X-Large

XX-Large

Passport #

Passport Date of Expiration

Upload an image of your passport OR come to the church office to create a copy.

Emergency Contact Name*

FirstLast

Emergency Contact Address*

Street AddressAddress Line 2CityStateZIP Code

Emergency Contact Phone*

Emergency Contact Email*

Emergency Contact Relationship*

Are You a Student?*

Yes

No

What grade or year in school?

Medical Insurance Provider Company*

Medical Insurance Provider Policy #*

Medical Insurance Provider Name Policy is Under*

Known Allergies*

Do tou know the date of your last Tetanus shot?*

Yes

No

Date of last Tetanus Shot

Could you estimate the date?

Would you like First Pres to arrange your airfare OR would you like to book your own airfare?